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From the horse's mouth (a.k.a. DSM-V)

I received my brand-spankin' new copy of the Diagnostic and Statistical Manual of Mental Disorders today, and spent some time transcribing the section on EDs. Thought this might clear up some confusion on the new classifications, etc. I also am cautious because I know this may raise questions, could be triggering (especially with the "severity levels"). Obviously you CANNOT DIAGNOSE YOURSELF - only a clinician can do that. And there are still murky areas. But let me know if you think this information is helpful. I highlighted some information I thought was particularly important to note.

Note: I did not include Pica, since it is quite rare to see a member suffering from this particular disorder.

DSM-V Feeding and Eating Disorders

Feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Diagnostic criteria are provided for pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder.

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.

Some individuals with disorders described in this chapter report eating-related symptoms resembling those typically endorsed by individuals with substance use disorders, such as craving and patterns of compulsive use. This resemblance may reflect the involvement of the same neural systems, including those implicated in regulatory self control and reward, in both groups of disorders. However, the relative contributions of shared and distinct factors in the development and perpetuation of eating and substance abuse disorders remain insufficiently understood.

Finally, obesity is not included in DSM-5 as a mental disorder. Obesity (excess body fat) results from the long-term excess of energy intake relative to energy expenditure. A range of genetic, physiological, behavioral, and environmental factors that vary across individuals contributes to the development of obesity; thus obesity is not considered a mental disorder. However, there are robust associations between obesity and a number of mental disorders (e.g., binge-eating disorder, depressive and bipolar disorders, schizophrenia). The side effects of some psychotropic medications contribute importantly to the development of obesity, and obesity may be a risk factor for the development of some mental disorders (e.g., depressive disorders).

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER - 307.59

DIAGNOSTIC CRITERIA:
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
5. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
6. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

ANOREXIA NERVOSA - 307.1

DIAGNOSTIC CRITERIA:
Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical heath. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

1. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
2. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtypes:
Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Specify current severity:
The minimum level of severity is based, for adults, on current body mass index (BMI) (see below), or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.

Subtypes:
Most individuals with the binge-eating/purging type of anorexia nervosa who binge eat also purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Some individuals with this subtype of anorexia nervosa do not binge eat but do regularly purge after the consumption of small amounts of food.
Crossover between the subtypes over the course of the disorder is not uncommon; therefore, subtype description should be used to describe current symptoms rather than longitudinal course.

BULIMIA NERVOSA - 307.51

DIAGNOSTIC CRITERIA:
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify current severity:
The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.
Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.
Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week.
Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors each week.

BINGE-EATING DISORDER - 307.51

DIAGNOSTIC CRITERIA:
Recurrent episodes of binge eating. An episode of binge eating is characterized by the following:
Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterwards.

Marked distress regarding binge eating is present.
The binge eating occurs, on average, at least once a week for 3 months.
The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Specify current severity:
The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The other specified feeding or eating disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder. This is done by recording “other specified feeding or eating disorder” followed by the specific reason (e.g., “bulimia nervosa of low frequency”).

Examples of presentations that can be specified using the “other specified” designation include the following:
1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months.
3. Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months.
4. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives; diuretics, or other medications) in the absence of binge eating.
5. Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external circumstances such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.

UNSPECIFIED FEEDING OR EATING DISORDER - 307.50

This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The unspecified feeding and eating disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific feeding and eating disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).

I attended medical school but am not working as a physician. PLEASE...when it doubt, get it checked out - by your own doctor.

Thanks for that Solita, that's really interesting. New textbook night definitely is my idea of a good night in!

I'm only really reiterating what you've just quoted, but I think it's worth repeating for people finding the numbers triggering (and for those of us in denial) - those BMI criteria are only MINIMUM severity. For example, if your BMI is in the 16-16.9 range, you are moderate or worse - your psychiatrist may still decide, based on your mental and physical health, that your disorder is severe or extreme. And a 'mild' eating disorder is still a serious illness.

Also (I have my clinician's hat on now), we are not REQUIRED to utilize criteria exactly as written. We don't have to use BMI at all to determine anything. I know that DSM-5 has much more focus on it than DSM-IV-TR, but clinical judgment continues to trump all.

Some UK doctors do use the DSM, others use the ICD-10, it's patchy - my MSc was taught from both ICD-10 and DSM-IV. I can copy in the ICD-10 criteria if anyone's interested? (And if that isn't completely hijacking Solita's thread?)

Some UK doctors do use the DSM, others use the ICD-10, it's patchy - my MSc was taught from both ICD-10 and DSM-IV. I can copy in the ICD-10 criteria if anyone's interested? (And if that isn't completely hijacking Solita's thread?)

Its very patchy!! They only use ICD in my area, they should at least all sing from the same hymn sheet!!

Well *I* think that's an exciting Friday night! I actually read your post on the edge of my seat. No joke!

SAAAAAAME ! Haha

"If I have any taste, it s for hardly anything
but earth and stones.

Let us eat air, rock, coal, iron.
Turn, my hungers.
Feed, hungers, in the meadow of sounds!
Suck the gaudy poison of the convolvuli;
Eat, the stones a poor man breaks,
the old masonry of churches, boulders,
children of floods, loaves lying in the grey valleys! "